Provider Demographics
NPI:1609063650
Name:ST ANTHONY'S PHYSICIAN ORGANIZATION PRIVATE PRACTICES LC
Entity Type:Organization
Organization Name:ST ANTHONY'S PHYSICIAN ORGANIZATION PRIVATE PRACTICES LC
Other - Org Name:SOUTH COUNTY ENDOCRINOLOGY & DIABETES CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:HINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-543-5903
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:STE 215
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-543-5285
Mailing Address - Fax:314-543-5238
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:STE 215
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-543-5285
Practice Address - Fax:314-543-5238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015650Medicare PIN